Articles: trauma.
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Rib fractures are associated with significant morbidity and mortality, and providing adequate analgesia is paramount in preventing early complications from these injuries. Multiple regional anaesthetic techniques can be used to provide analgesia for these injuries; however, few evidence-based guidelines exist for their use. The aim of this study was to establish consensus within an expert group on the selection criteria used when choosing regional anaesthetic techniques for rib fractures. ⋯ This e-Delphi study succeeded in building consensus across multiple statements relating to the selection criteria for regional anaesthesia in patients with rib fractures. These consensus statements can inform clinical practice, guide future research priorities and can be integrated into decision-making pathways across multiple hospital settings.
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Observational Study
The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting.
Acute Traumatic Coagulopathy (ATC) is a complex pathological process that is associated with patient mortality and increased blood transfusion requirements. It is evident on hospital arrival, but there is a paucity of information about the nature of ATC and the characteristics of patients that develop ATC in the pre-hospital setting. The objective of this study was to describe the nature and timing of coagulation dysfunction in a cohort of injured patients and to report on patient and pre-hospital factors associated with the development of ATC in the field. ⋯ Clinically significant, multifaceted coagulopathy develops early in the clinical course, with hypofibrinogenemia being the predominant coagulopathy. In keeping with the ED literature, pre-hospital coagulation dysfunction was associated with mortality and early massive transfusion. Further work is required to identify strategies to identify and guide the pre-hospital management of the coagulation dysfunction seen in trauma.
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Providers caring for hospitalized patients with difficult intravenous access (DIVA) frequently use central venous catheters (CVCs). One potential alternative is a peripheral internal jugular (PIJ) catheter, which is less traumatic to place and has fewer lumens than a CVC. ⋯ Catheter failure rate within 7 days was 32.4%, though it varied across catheter types: 9.5% in 8-10 cm midline catheters versus 69.2% (p < .001) in 6 cm angiocatheter wire introducers or shorter peripheral intravenous catheters. Our results suggest that PIJ catheters may be an option to reduce the mechanical and infectious risks associated with CVCs in some hospitalized patients with DIVA.
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The Assessment of Blood Consumption (ABC) score is a previously validated scoring system designed to predict which severely injured trauma patients will require massive transfusion. When the ABC score is used in the prehospital setting to activate massive transfusion at the receiving hospital, a 23% decrease in mortality has been demonstrated. However, the ABC score was developed and validated using hospital data from the emergency department (ED). The sensitivity and specificity of the ABC score when calculated using data from the prehospital setting are unknown. We hypothesized that the sensitivity and specificity of the prehospital ABC score will be similar to the sensitivity and specificity of the ED ABC score. ⋯ The ABC score is a useful prehospital tool for identifying who will require massive transfusion. Future studies to evaluate the effect of the prehospital ABC score on clinical care and mortality are necessary.
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Patients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR). ⋯ In patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.